Mitigating the mental health consequences of mass shootings: An in-silico experiment
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Articles
Mitigating the mental health consequences of mass
shootings: An in-silico experiment
Salma M. Abdalla,a* Gregory H. Cohen,a Shailesh Tamrakar,a Laura Sampson,b Angela Moreland,c
Dean G. Kilpatrick,c and Sandro Galea a
a
Epidemiology Department, School of Public Health, Boston University, Boston, United States
b
Epidemiology Department, Harvard T.H. Chan School of Public Health, Boston, United States
c
Medical University of South Carolina, South Carolina, United States
Summary
Background There is emerging evidence that mass shootings are associated with adverse mental health outcomes at eClinicalMedicine
the community level. Data from other mass-traumatic events examined the effectiveness of usual care (UC), 2022;51: 101555
(i.e., psychological first aid approaches without triage), and stepped care (SC) approaches, with triage, in reducing Published online 22 July
2022
the burden of post-traumatic stress disorder (PTSD) in a community.
https://doi.org/10.1016/j.
eclinm.2022.101555
Methods We built an agent-based model of 118,000 people that was demographically comparable to the population
of Parkland and Coral Springs, Florida, US. We parametrized the model with data from other traumatic events.
Using simulations, we then estimated the community prevalence of PTSD one month following the Stoneman
Douglas High School (Florida, US) shooting and reported the potential reach, effectiveness, and cost effectiveness of
different what-if treatment scenarios (SC or UC) over a two-year period.
Findings One month following the mass shooting, PTSD prevalence in the community was 11.3% (95% CI: 11.1
−11.5%). The reach of SC was 3461 (95% CI: 3573−3736) per 10,000 and the reach of UC was 2457 (95% CI: 2401
−2510) per 10,000. SC was superior to UC in reducing PTSD prevalence, yielding, after two years, a risk difference
of 0.044 (95% CI, 0.046 to 0.042) and a risk ratio of 0.452 (95% CI, 0.437−0.468). SC was also superior to
UC in reducing the persistence of PTSD, yielding, after two years, a risk difference of 0.39 (95% CI, 0.401 to
0.379) and a risk ratio of 0.452 (95% CI, 0.439−0.465). The incremental cost-effectiveness of SC compared to UC
was $2718.49 per DALYs saved, and $0.47 per PTSD-free day.
Interpretation This simulation demonstrated the potential benefits of different community-level approaches in mit-
igating the burden of PTSD following a mass shooting. These results warrant further research on community-based
interventions to mitigate the mental health consequences of mass shootings.
Funding None.
Copyright Ó 2022 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Keywords: Mass shootings; Post-traumatic stress disorder; Mental health; Cost effectiveness; Stepped care;
Psychological first aid
Introduction evidence that the families and loved ones of those
Mass traumatic events are associated with an increased directly affected and their communities all experience
burden of a wide range of mental disorders including an elevated burden of mental illness after mass
posttraumatic stress disorder (PTSD).1 These psycholog- traumatic events.1,2 The literature on the psychological
ical consequences can be experienced beyond those who consequences of mass shootings is more limited
were physically injured or were in direct physical danger than for other mass traumatic events. However, there is
during the mass traumatic event. There is ample emerging evidence that mass shootings are associated
with adverse mental health outcomes—particularly
PTSD—among both survivors and their communities.3
*Corresponding author at: Epidemiology Department, School Despite the potential increased burden of mental ill-
of Public Health, Boston University, 715 Albany Street - Talbot ness, there is often substantial unmet need for mental
510E, Boston, MA 02118. health services in the aftermath of mass traumatic
E-mail address: abdallas@bu.edu (S.M. Abdalla). events.4 For example, following the September 11, 2001
www.thelancet.com Vol 51 September, 2022 1Articles
Importantly, many do not receive any form of assistance
Research in context to begin with, not even psychological first aid.
Given these challenges, stepped care (SC) interven-
Evidence before this study tions have emerged as a potential alternative to tackle
We searched PubMed for studies published until May 20, the mental health consequences of traumatic events
2022, using the terms ((Treatment) OR (“Community Men- and improve the reach of mental health services.10,11 SC
tal Health Services”[Mesh] OR “School Mental Health Serv- interventions include screening and triage of services to
ices”[Mesh] OR “Mental Health Services”[Mesh])) AND the appropriate level of mental health care, followed by
(“Stress Disorders, Post-Traumatic”[Mesh])) AND ((mass ongoing systematic re-evaluation. The SC approach has
shooting) OR (“Gun Violence”[Mesh])). We found 11 clear utility and has been recommended in the context
articles. The literature highlighted the importance of psy-
of disasters.12 To our knowledge, however, there have
chosocial interventions following mass shooting events.
been no trials examining the reach and effectiveness of
Overall, studies focused on services at the individual level,
supporting survivors through therapy and psychiatric SC interventions following mass shootings.
assessments with the goal of increasing self and commu- We developed an in-silico experiment to
nity efficacy and encouraging hope and belief that recov- investigate the potential reach, cost effectiveness, and
ery from traumatic events is possible. However, the reduction of burden of PTSD in a community following a
literature on community interventions for mental health mass shooting under various what-if treatment scenarios
support remains limited. using different mental health services approaches—SC
and usual care (UC). In this simulation study, UC refers
Added value of this study to a psychological first aid intervention without triage. Our
In this simulation, we suggested the potential benefits goal was to assess: (1) The reach of either SC or UC in a
of two community-level approaches— psychological two-year period; (2) The predicted reduction in the preva-
first aid and stepped care—in mitigating the burden of lence of PTSD in the full population for either approach;
posttraumatic stress disorder following a mass shooting. (3) The predicted proportion of PTSD cases that persist
over time for either approach; and (4) The incremental
Implications of all the available evidence cost-effectiveness of SC compared to UC.
This study highlights the need for further research—
particularly research that focuses on improving the
reach of interventions—and real-world application of
community-based interventions to address the mental
Methods
health consequences of mass shootings. We used agent-based models (ABMs) to simulate the
burden of PTSD in the community following the
Stoneman Douglas High School (Parkland) shooting.13
ABMs allow for the development of counterfactual
estimates of treatment effects, when given appropriate
terrorist attacks only 26.7% of persons with severe psy-
inputs.14 The outcomes measures we selected were
chological symptoms received treatment.5 Such unmet
guided by the population impact framework to accu-
need frequently persists despite efforts to provide serv-
rately capture the predictive values of the proposed
ices for the affected populations.6,7
treatment scenarios. This framework defines impact
Psychological first aid interventions are often the
by measuring the proportion of participants who
first line of mental health services implemented in the
received an intervention—i.e. reach—and by the
aftermath of mass traumatic events.8 Psychological first
reduction in the incidence or prevalence among those
aid interventions include providing physical and emo-
who received the intervention.15
tional support as well as practical assistance to address
immediate needs following a mass traumatic event.
Such interventions aim to reduce distress and improve Model structure
adaptive functioning—often without triage. People who We built an agent population that was demographically
continue to have psychological symptoms after receiv- comparable to the population of Parkland and Coral
ing psychological first aid, especially if they persist for Springs, Florida. We added Coral Spring to the model
over 2 months, may benefit from approaches of higher to be able to have a sufficiently large population to run
intensity such as evidence-based trauma-focused cogni- our model and estimate results. Coral Spring was partic-
tive behavioral therapy (CBT) or pharmacotherapeutic ularly relevant as this was the area the shooter was
therapy. However, evidence suggests that without tri- apprehended. Using this agent-based population, we
age, persons who require high-intensity services may be simulated treatment scenarios beginning four weeks
underserved under psychological first aid interven- after the Parkland shooting and ending two years later.
tions.9 Moreover, psychological first aid services are We chose four weeks to distinguish between symptoms
often offered to direct survivors—and sometimes their of acute distress disorder—which arise and resolve by
families—not to community members in general.8 four weeks after a traumatic event—and PTSD.
2 www.thelancet.com Vol 51 September, 2022Articles
Agent population Our model assumed that, among those who did not
We initialized a population of 118,000 agents to serve as receive care,14% underwent remission without treat-
an approximation of the population of Parkland and ment. This proportion corresponds to the mean from a
Coral Springs, Florida. The demographic (sex, age, and meta-analytic estimate for remission among survivors
race/ethnicity) parameters for this synthetic population of a wide range of traumatic events receiving psycho-
were applied using data derived from the 2011-2015 therapy in trial waitlist control conditions.23 We chose
American Community Survey 5-year population esti- the mean because assaultive violence-related events are
mates for Parkland and Coral Springs, Florida.16 among the more potent types of traumatic events.24
Among those who recovered, our model assumed that
15% experienced recurrence of PTSD after symptom reso-
Levels of exposure lution. We chose 15% to split the difference between recur-
We designated within our model three levels of expo- rence and relapse rates of up to 34% from samples of
sure to the shooting: primary, secondary, and tertiary. mixed traumatic exposure,25 and studies that report lack of
Primary exposure included persons who were injured relapse when examining the trajectories of PTSD symp-
or present and in danger of being shot at the site of toms following events of mass violence.26 We also con-
mass shooting. This level included 900 students and 30 ducted a sensitivity analysis that used the highest reported
adults based on the average number of persons present rate (34%) for recurrence and relapse. Details of the esti-
each day at Stoneman Douglas High School.17 Second- mates are provided in Supplement. Further, among agents
ary exposure included direct family or friends of those who underwent relapse in our model, PTSD symptoms
primary affected by the shooting. We built an internal returned to 80% of the initial symptom levels.
social network to connect agents directly affected with
agents assigned as family or close friends. Ultimately,
secondary exposure included 4725 agents. Tertiary expo- Intervention components
sure included persons who were not directly affected by As shown in Figure 1, we assessed the reach, treatment
the shooting and did not have family or friends affected effectiveness, and cost effectiveness based on
by the shooting, but were living in the affected commu- approaches: SC and UC.
nity at large, which included 112,189 agents.
Usual care. In the model, UC included the provision of
Skills for Psychological Recovery (SPR) indiscriminately
PTSD prevalence and symptoms score estimates
within the affected community. SPR is an intermediate-
We parameterized PTSD prevalence in the past month
level intervention (which follows the design of psychologi-
for different age groups (14-17, 18-34, 35-64, or ≥65
cal first aid) that aims to reduce distress and improve cop-
years) from prior studies that used the diagnostic and
ing and functioning.7 The intervention may also lower the
statistical manual of mental disorders (DSM-IV) crite-
need for formal mental health treatment. In our model,
ria18 to estimate the initial distribution of PTSD preva-
five sessions of SPR reduced an agent’s symptoms by
lence for each exposure level in the aftermath of a mass
20%. We also conducted sensitivity analyses using a
shootings or other mass traumatic events.19−21 We
reduction in agent’s symptoms by 15% and 25%.
selected 14 years as the lower age limit because that is
the average age of students admitted to the Stoneman
Douglas High School. We then used the sex ratio of Stepped care. In the model, SC included a triage screen-
PTSD prevalence from a study20 reporting on primary ing step during initial entry to services. Through SC,
exposure data to estimate PTSD prevalence by sex for agents were assessed for PTSD case status; identified cases
adults within the secondary and tertiary levels. To test were offered CBT and non-cases were offered SPR. Per the
the dependence of our results on variation in commu- International Society for Traumatic Stress studies guide-
nity PTSD prevalence, we conducted a sensitivity analy- lines, CBT took place for eight sessions in the model.27 A
sis with a different tertiary PTSD prevalence from a course of CBT reduced an agent’s symptoms by 36%. This
survey that examined the community burden of PTSD percentage is based on the reduction in PTSD symptoms
following another mass traumatic event.22 Details of the experienced in a three-month period by participants in the
estimates are provided in Supplement. CBT arm of a randomized clinical trial.28 In this model,
Guided by the DSM-IV PTSD checklist as the gold we allowed for up to eight extra sessions for agents who
standard, we used data from a prior study to estimate did not recover after the initial eight sessions.
the number of symptoms (range, 0-17) corresponding
to the demographic parameters of agents in our simula-
tion.22 Accordingly, we set the cutoff point to identify a Treatment seeking behavior. We used prior data that
true case of PTSD (probable PTSD diagnosis) in our aimed to examine determinants of PTSD following the
simulation at six symptoms. We used sensitivity and September 11th, 2001, terrorist attacks to estimate proba-
specificity of 0.80 in our model. bilities of enrollment in, and use of, SPR and CBT
www.thelancet.com Vol 51 September, 2022 3Articles
Figure 1. Overview of the agent-based model structure and flow. Figure 1 presents a visual representation of the agent-based
model structure and flow.
treatments.22 These probabilities were estimated for effectiveness ratios (ICER) among initial cases for
cases and non-cases separately, accounting for age, sex, simulated comparison. DALYs provide a standard-
and race/ethnicity. ized measure for estimating years of healthy living
lost due to disability. We derived disability weights
Outcome measurement from the global burden of disease study,22 specified
as mild (0.03), moderate (0.149), and severe (0.523)
Reach. As an overall measure, we reported the reach of disease states.
each treatment scenario. We defined reach as the num- PTSD-free days are the number of days spent by an
ber of agents who accessed treatment per 10,000 in the agent in non-case status throughout the simulation.
affected population. Our model takes a healthcare cost perspective and
within it, we applied the ICER calculations for a horizon
Treatment Effectiveness. We reported treatment effec- of a ten-year time—accounting for a discounting rate of
tiveness using both risk differences and risk ratios. 3% on effectiveness and future cost. Details of ICER cal-
These measures were calculated for increments of culations are described in Supplement.
three-month periods for the duration of the simulation.
Statistical analysis
Treatment Cost. Based on prior assessment of in-per- Each of the interventions was run for 100-time steps,
son delivery costs, we set the cost of CBT at $60 per ses- starting four weeks after the shooting and representing
sion.6 Because we did not have real-world data on the passage of two years after the mass shooting in total.
average costs for SPR, we made an assumption—based These ABMs were developed using C++ and imple-
on earlier simulations—that costs per person, per group mented using Microsoft Visual Studio 2012 (Microsoft
session, would be $15.6 To examine how cost fluctuation Corp). We ran each model scenario 50 times to account
is linked to cost effectiveness, we conducted a sensitivity for the stochasticity in the modeling process, with mean
analysis raising the costs of CBT to $120 per session statistical measures reported. We then computed the
and SPR to $30 per person per session. 2.5th and 97.5th percentiles across those 50 simulations.
Supplement provides an overview of the design concept
Incremental cost-effectiveness. Using disability- and detailed protocol for this study including sub-mod-
adjusted life years (DALYs) and PTSD-free days as els, pseudocodes, and a more in-depth focus on the
measurements, we computed the incremental cost- design concepts.
4 www.thelancet.com Vol 51 September, 2022Articles
Boston University Institutional Review Board waived higher than that of UC in the subsequent sensitivity
approval for this study as the parameters used were analyses, as shown in Supplement.
based on publicly available literature or derived from
anonymized publicly available data.
Treatment effectiveness
Figure 2 demonstrates the treatment effectiveness of
Role of the funding source both SC and UC in reducing the population prevalence
There was no funding source for this study. of PTSD. SC began yielding a lower PTSD prevalence
than UC starting at three months (RD, -0.004; 95%
CI,-0.007 to -0.002), with the absolute benefit (risk dif-
Results ference) continuing to gradually improve through the
end of the two years (RD, -0.044; 95% CI, -0.046 to
As shown in Table 1, our simulated synthetic population
-0.042). Relative benefit (risk ratio) of SC was clear at
closely resembled the population distribution in terms
three months (RR, 0.963; 95% CI, 0.941 to 0.986),
of age, sex, race/ethnicity, and education of the 2011-
with continued gains through the end of the two years
2015 American Community Survey 5-year population
(RR, 0.452; 95% CI, 0.437 to 0.468). As shown in Sup-
estimates for Parkland and Coral Springs, Florida.16
plement, the sensitivity analysis assuming a different
Our model estimated that the overall PTSD prevalence
tertiary PTSD prevalence yielded comparable results.
in the community following the Parkland shooting was
Figure 3 demonstrates the treatment effectiveness of
11.3% (95% CI: 11.1−11.5%). In the sensitivity analysis
both SC and UC in reducing persistence of PTSD. SC
using different a tertiary prevalence, the community
was superior to UC in reducing persistence of PTSD:
prevalence remained high at 8.7% (95% CI: 8.5−8.6%).
absolute benefit was clear after three months (RD,
-0.042; 95% CI, -0.047 to -0.036) and increasing
Reach through the end of the two years (RD, -0.390; 95% CI,
The reach of SC was 3461 (95% CI: 3573−3736) per -0.401 to -0.379). Relative benefit of SC was clear at 6
10,000 and the reach of UC was 2457 (95% CI: 2401 months (RR, 0.786; 95% CI, 0.743 to 0.832), with con-
−2510) per 10,000. The reach of SC was similarly tinued gains through the end of the two years (RR,
Demographic group Broward Country, FL population Model Population %
(2011−2015 ACS Estimates) % (N = 1,728,265)
(N = 1,843,152)
Sex
Female 51.452 51.142
Male 48.548 48.858
Age
Under 20 years 24.01 24.38
20 to 44 years 33.15 33.38
45 to 64 years 27.83 27.74
65 and over 15.01 14.50
Race/Ethnicity
White (Non-Hispanic) 40.397 40.074
Hispanic 26.976 26.779
Black (Non-Hispanic) 26.904 27.199
Asian (Non-Hispanic) 3.430 3.446
American Indian and Alaskan Native (Non-Hispanic) 0.169 0.237
Some other race (non-Hispanic) 0.454 0.521
Two or more race (non-Hispanic) 1.670 1.743
Education
Up to 12th grade 12.362 12.644
High School 27.832 28.085
Some College 21.766 21.537
Associate degree 9.620 9.641
Bachelor's degree 18.480 18.442
Graduate degree 9.940 9.651
Table 1: Comparison of Broward Country ACS estimates with Model synthetic population.
www.thelancet.com Vol 51 September, 2022 5Articles
Figure 2. Treatment effectiveness of stepped care and usual care in reducing PTSD prevalence among the full population.
Figure two shows the effectiveness of stepped care (blue color) and usual care (green color) in reducing population PTSD prevalence
over two years (base case model). Sensitivity = 0.80 and specificity = 0.80.
Figure 3. Treatment effectiveness of stepped care and usual care in reducing PTSD prevalence among cases. Figure three
shows the effectiveness of stepped care (blue color) and usual care (green color) in reducing PTSD persistence among cases over
two years (base case model). Sensitivity = 0.80 and specificity = 0.80.
0.452; 95% CI, 0.439 to 0.465). As shown in Supple- both SC and UC reported total costs for SC of
ment, the sensitivity analysis assuming a different ter- $9,510,610 and a total cost of UC of $1,885,500. ICER
tiary PTSD prevalence yielded comparable results. for SC compared to UC was $5429.32 per DALYs
averted and $0.95 per PTSD-free days. As shown in
Supplement, other sensitivity analyses showed compa-
Cost effectiveness rable results.
As shown in Table 2, the total cost of the SC interven-
tion was $4,758,260 and the total cost of UC was
$943,207. The ICER for SC compared to UC was Discussion
$2718.49 per DALYs averted and $0.47 per PTSD-free In this paper, using ABMs assessing the efficacy of SC
days. The sensitivity analysis assuming higher costs for or UC approaches in the aftermath of the Parkland
6 www.thelancet.com Vol 51 September, 2022Articles
Parameters Mean cost Total Cost ($) DALYS avoided PTSD-Free Days ICER ICER
/Person ($) ($ per DALY averted) ($ per PTSD-Free Day)
Scenario 1: Base Case
(CBT cost $60/Session, SPR Cost = $15/Session)
Usual Care 70.93 943,207 3368.07 28,612,300 - -
Stepped Care 360.58 4,758,260 4771.44 36,665,300 2718.49 0.47
Scenario 2: Sensitivity Analysis with higher costs
(CBT cost $120/Session, SPR Cost = $30/Session)
Usual Care 141.85 1,885,500 3370.38 28,594,900 - -
Stepped Care 720.98 9,510,610 4774.82 36,633,500 5429.32 0.95
Table 2: Cost-effectiveness with a discounting rate of 3%.
The simulation begins 4 weeks following the mass shooting. ICER: incremental cost effectiveness ratios.
mass shooting, we demonstrated the potential benefits modeling beyond Parkland, the area surrounding the
of different community-level approaches in mitigating Stoneman Douglas High School, to include Coral Springs
the burden of PTSD following a mass shooting. SC was to build the model population. Moreover, these assump-
associated with greater reach and higher effectiveness tions were based on the results of several epidemiological
in reducing the prevalence of PTSD in the population. studies; each of the studies have its own limitations. How-
Overall, SC was costlier than UC. The ICER for SC per ever, the parameters we used to initialize our model have
DALYs saved ($2718.49), and per PTSD-free day many strengths and afford confidence in the estimates pro-
($0.47) were, nonetheless, well below the acceptable vided by our simulation. Further, we see this simulation as
cost-benefit value for interventions in the United States an essential, formative work, paving the way for real-world
(i.e.,Articles
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Contributors treatment and cost-effectiveness of a stepped care case-finding
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